INTERNATIONAL JOURNAL OF MOTOR SPORT MEDICINE ISSUE#12, NOVEMBER 2017

ADVANCES IN EXTRICATION How motor sport rescue teams deal with cutting open tough modern cars P24 ON SITE AT PAUL RICARD A look at the medical operation at the new host of the French Grand Prix P30 SÉBASTIEN BOURDAIS The IndyCar star shares his story of recovery from his 227MPH crash P34

FAST ASLEEP How racing drivers beat fatigue and jet lag with science AUTO+MEDICAL AUTO+MEDICAL

Welcome to the new issue of AUTO+ Medical, featuring the latest news from the world of motor sport medicine.

In our cover story, we take a medical look at LETTERS/ how drivers deal with jet lag and tiredness when competing in global motor sport, P4 The best letters and emails received from readers around the world often crossing continents on a weekly basis. GLOBAL NEWS/ P6 Injury round-up: several drivers return to racing We speak to my friend and FIA Safety P7 Williams develops 'Babypod' infant transport capsule Director Laurent Mekies about his important P7 McLaren creates 3D-printed medical breastplate work in motor sport. We also take a look at P7 FIA launches Disability and Accessiblity Commission the evolution of rescue teams in racing, P8 FIA set to introduce biometric gloves to Formula One P9 Tiago Monteiro ruled out of WTCC races after testing crash and the challenges they face today in P9 Spectators injured by burning fuel at Australian drag racing event cutting open the super-strong cars of P9 Isle of Man motor sport association receives new rescue ambulance modern times.

FEATURES/ We go inside the Medical Facility at Circuit P10 FAST ASLEEP Paul Ricard, and see how the medical team Racers today compete across several time zones. We speak to is preparing for the return of the French drivers and doctors about how they avoid jet lag and tiredness. Grand Prix, after a decade off the Formula P18 BIG INTERVIEW: LAURENT MEKIES The FIA's Safety Director talks about his many roles in motor sport, One calendar. and how they all come together to help him improve safety. P24 THE CUTTING EDGE In our Road Back feature, we speak to A look at the challenges faced by motor sport rescue and extrication IndyCar Series race-winner Sébastien teams as racing cars continue to get stronger . Bourdais about his high-speed accident P30 INSIDE CIRCUIT PAUL RICARD'S MEDICAL FACILITY during Qualifying for the 2017 Indy 500, An inside view of how the Le Castellet Circuit is upgrading its facilities in preparation for the first French Grand Prix since 2008. and how he recovered from it. P34 THE ROAD BACK: SÉBASTIEN BOURDAIS The IndyCar racer talks about his high-speed crash during qualifying Finally, in our Scientific Article, we take a for the 2017 Indy 500, and how he returned just three months later. look at the increased incidence of concussions in motor sport, and the STUDY/ importance of understanding the condition. P40 CONCUSSION IN MOTOR SPORT: A MEDICAL LITERATURE REVIEW A detailed study appraising the current literature concerning I hope you enjoy the latest issue. concussion in motor sport

Editor: Marc Cutler Deputy Editor: Charlie Eustice Designer: Cara Furman Prof. Gérard Saillant, We welcome your feedback: [email protected] President, FIA Medical Commission 2 AUTO+MEDICAL LETTERS AUTO+MEDICAL LETTERS

Dear editor, how often a significant fire occurs. Does that go for Following the excellent feature in the last issue about “a little” bit of extrication as well? Polymers, plastics, In this section, we print the best letters and emails received from readers around the Fire Simulation Training, I wanted to raise another composites, combustible alloys and related materials important point about firefighting in the motor sport are bad news in a fire. But had anyone done any world. We welcome comments on articles as well as suggestions for future content. If environment - respiratory protection. real research into this issue of Personal Protective you wish to send in a letter or email, please direct it to: [email protected] When we speak of vehicle fires today, at least from Equipment (PPE) for responders and especially a respiratory protection standpoint, the best practices respiratory protection in the realm of vehicles fires? approach from a worldwide perspective: There is quite a bit of material about passenger Dear Editor, I did not know what happened when a cutting team “Don positive pressure self-contained breathing vehicle fires where the amount of toxins, acids, toxic Earlier this year, I was involved in a multi-car is called out. I did not know how to maintain a calm apparatus during suppression operations and also particulates and hazardous dusts can be significant. accident at Croft during qualifying for the fifth and steady position once my lungs had punctured during post suppression overhaul operations while In all of the studies, SCBA has been an essential round of the British Touring Car Championship and limbs had broken whilst still trapped inside the smoke and vapor & particles are present” recommendation for personnel at these incidents. (BTCC). car. It was completely down to the professionalism Well that’s basically the entire event. However, Admittedly, while one can wear SCBA at the track, The accident began at the entrance to the Jim Clark of the extraction team and medical staff not only to this is on public roads, streets, highways, motorways there are events that are at least 2+ hours in length Esses and finished 400 yards later on the exit of get me out of there safely and quickly, but to achieve etc. What of motor sport? We rarely ever see Self- for instance endurance races that may be 12 or 24 Barcroft, the fastest corner on the circuit. all that whilst guiding me through every step and Contained Breathing Apparatus (SCBA) at a motor hours long. This additionally means that many spare Prior to that moment, in truth, I was unaware of assuring that I remained in a stable and cooperative sport venue. At least not seemingly beyond tokenism. air cylinders are needed ready for swap. the real risks that I was taking every time I went condition. Why is this? I watched the Australian GP and one So are there options instead of SCBA? Here are out on track. I think those close to me and even the I cannot fathom the pressure they must have of the Haas F1 cars came in with an apparent fire in some options. wider BTCC community did not anticipate such an worked under. Especially when one considers the its engine bay. No visible fire but quite a bit of smoke. The first is a mask from Respiro called FB-1. It accident in this day and age. fact that this pressure was threefold. Three drivers, When the car stopped and as the driver started to exit was designed for the fire service in the UK and for Thinking back to the start of the year, I was so three sets of families, friends and loved ones, teams the vehicle there were 2 pit road firefighters with dry the overhaul period post structure fire. It was also ignorant I even assured my girlfriend that an and supporters. In the hours, days and weeks power extinguishers and 3 Haas crew members with designed to be proof against dust and particles at a accident causing serious injury would be almost after the accident, the support remained for not Foam APW extinguishers at the vehicle with the Haas motor vehicle crash. The mask was able to be donned impossible. just the drivers but their families too. The affect crew actively putting agent onto the vehicle. and doffed with all PPE in place due its Velcro closure However, an unfortunate set of circumstances this had on my loved ones in particular cannot be Good job by all, at least by appearances especially and it has two replaceable filters in the front. led to a serious accident occurring, which in turn underestimated. Dr Paul Trafford's words of comfort with what looked like a wetting agent not a foam! A second option is a RZ mask designed for the resulted in myself and two other drivers sustaining to my Dad instigated a feeling of stability and security But not one person had any form of respiratory public safety environment. The filter is above the wide-ranging injuries. The urgency and pressure which was key to my recovery and my family’s sense protection. Most of you will say “those cars don’t have grade of an N95 with active carbon fiber filtration put on the medical staff of the BTCC must have of wellbeing. a large fuel load”. Really? Besides carrying enough for chemicals as well as for dusts & fibers plus just been immense. The actions of those urgent minutes have a lasting fuel for entire race there’s a high energy battery, most like the FB-1 mask it has replaceable/changeable I can report with confidence that the common affect on all involved. of the body is made from composite material of one filters. We really do not have any PPE now in use at paddock joke of extraction team members, For me, I count myself so lucky that I was in the kind or another and combustible alloys. The smoke motorsport events to protect our respiratory tract. Doctors and ambulance drivers being on site to hands of the BTCC medical staff. I have attended all also hides various acids and gases that are toxic to Along with this we need to take a serious look at keep coffee and biscuit supplies under control, is but one of the BTCC races since the accident and breathe. research into PPE in the motor sport environment. indeed a complete myth! I feel such a bond with staff who I am ashamed to When dealing with car fires on public roads, SCBA We need to demonstrate for real not theorize what My memory of the second part of the crash and say, I don’t even know the names of. Yet they are still is worn during suppression and overhaul operations is hurting us short and long term. We need to strive the aftermath is minimal. there, eating their biscuits and drinking the coffee, basically whenever there is a possibility of smoke, to make improvements in all areas of our PPE but That is a very key point in what I would like to put absolutely ready for the next time something like this vapors and particles released into the air. So why not especially in the area of respiratory protection. across. I believe that in situations like the accident unfortunately happens. at axxxxxx race track? at Croft, we are completely in the hands of the Costxxxxxxx and logistics can be a consideration for both David Dalrymple AIETecRI amazing professionals who give up their weekends Luke Davenport the xxxxxxxxinitial outlay and subsequent upkeep. A frequent FF/EMT/Rescue Technician, Clinton EMS/ to ensure our safety. Driver, British Touring Car Championship argument is that such an investment is overkill for Rescue/Fire Technician, American Rally Association

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WILLIAMS The breastplate DEVELOPS incorporates FIA LAUNCHES ‘BABYPOD’ F1 technology COMMISSION FOR DISABLED RACING GLOBAL Williams Advanced Engineering has utilised F1 technology to The FIA is creating a Disability and develop a high-tech Accessibility Commission to advise infant transportation on strategies to encourage and capsule for carrying allow participation in motor sport babies to hospitals. for people with disabilities. The ‘Babypod 20’ is a Motor racing is one of the few NEWS sports where disabled drivers lightweight box with a transparent lid, MCLAREN compete alongside able-bodied ensuring safe drivers. This was demonstrated by transportation of DEVELOPS 3D quadruple amputee driver critically ill babies to Frédéric Sausset, who completed hospital. PRINTED MEDICAL the 2016 Le Mans 24 Hours Race. The outer casing is Another driver, Nathalie made from carbon fibre, BREASTPLATE McGloin, became the first female a technology used in the with a spinal cord injury to be design of Williams' granted a racing licence in the UK. Formula One cars, and McLaren’s advanced technology arm has Speaking recently at the FIA Sport the inside is padded to developed a bespoke 3D-printed wearable Conference, she talked about the ensure comfort for the breastplate to protect internal organs. importance of ASNs adapting their regulations to ensure inclusivity. Luke Davenport infant within. Named ‘Project Invincible’, McLaren “The MSA in the UK is looking at sustained severe Babies require very Applied Technologies designed the product injuries, but has careful transportation to protect the thorax region of the body, improving the process for injured returned to the cockpit with minimal vibration ultimately acting as an exoskeleton in place people to pass their race licence. after five months. or noise, and must be of the rib cage. For me, having someone assess kept at constant Commissioned by an anonymous client your abilities directly is key.” temperatures. The following thorax surgery, McLaren She also highlighted the Babypod 20 ensures all measured his chest region via 3D scanning, importance of maintaining the these criteria are met, ensuring that the plate would fit perfectly highest safety standards, adding: RACERS RETURN FROM INJURY and the transparent lid to the contours of the body, protect from “These regulations need to be put allows close inspection impacts as well as transfer and attenuate in place to demonstrate that for medical staff. forces away from the affected region. disabled racing is safe racing.” A number of top drivers have returned to racing in his leg, he reported there was “no physical pain”. The device weighs 9.1 The client’s surgery had left him with a The new commission will aim to recent weeks following injury. He is aiming to be back to fitness for the 2018 kilograms and costs compromised left rib cage, sternum and encourage even more disabled One of the most notable comebacks has been made season, where he hopes to compete again for £5,000, and is already kidney, and living in fear of causing further drivers to compete in motor sport. by British Touring Car Driver Luke Davenport, who Motorbase Performance. The first round of the season being used by Great injury to the body by performing simple returned for the first time since a crash in June left him is at Brands Hatch on 7-8 April. Ormond Street Hospital everyday tasks. in a coma. NASCAR racer Aric Almirola made a return to racing in London, with plans to The device was created through a He sustained major injuries during Qualifying at the in the New Hampshire NASCAR Cup race following a market it more widely collaboration involving multiple divisions of Croft Circuit, when an oil leak sent him and several back injury sustained earlier in the season. in the future. the company, along with Stratasys, a others off-track. Davenport crashed into fellow racer Almirola suffered a partially crushed vertebra in his 3D-printing manufacturer with whom Jeff Smith, and suffered a shattered pelvis, a broken back when he slid into Joey Logano’s stricken car at McLaren has been working to print pieces right leg, broken right arm, and chest and lung damage, Kansas Speedway in May. The Richard Petty Racing The carbon fibre casing for its Formula One cars. before being placed in a medically induced coma for driver however has since made a full recovery. shares Williams F1 DNA. The plate was made from a lightweight several weeks. IndyCar star Sébastian Bourdais, meanwhile, composite made from Dyneema fibers, He completed 10 laps of Snetterton circuit on 7 returned to the cockpit in a mid-season test at Mid- which are used in body armour, for November, driving a Motorbase Performance-run Ohio after suffering a fractured pelvis, hip and two damage containment, plus a tough resin Volkswagen Golf TCR. broken ribs during qualifying for the Indianapolis 500. with woven fabrics for impact resistance. Though he has a cage screwed to his pelvis, a plate to See Page 34 for a full interview with Bourdais about his Zylon fibres, which are used in F1 cars, and protect his damaged shoulder, and a rod inserted into return to racing. stiff carbon fibres, were also incorporated.

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BIOMETRIC WTCC STAR SIDELINED AFTER The gloves will be GLOVES SET TO BE ubiquitous for the 2018 TESTING CRASH NEW AMBULANCE INTRODUCED INTO F1 F1 season, measuring FOR ISLE OF MAN signs of all drivers. Honda World Touring Car star spoke about his condition MOTOR SPORT The FIA is set to introduce a new race Tiago Monteiro was left immediately after the incident: glove into Formula One that sends hospitalised following a test crash “The main issue I had was the at Barcelona. concussion in my head with two potentially life-saving data from driver The Isle of Man’s Hogg to medical crew. Monteiro suffered 255kph blood clots. Then the vertebrae, crash at the Circuit de Catalunya the eyes and the nerves, that Motorsport Association has Stitched into the glove is a flexible taken delivery of a new Peugeot sensor, measuring just 3mm in while testing for the Honda WTCC were squeezed by the blood. team during the mid-season “If there was just a little more ambulance as part of its plans thickness. It is the sport’s first to phase out its older vehicles. biometric monitoring device and is set break. blood or a bigger tear in my neck I The Portuguese driver’s brakes would have been unable to move, With help from The Manx to be inserted into every drivers’ Lottery Trust, a delegated gloves next season in a bid to monitor failed as he approached the first or even worse. I was very lucky.” corner, sending his Honda Civic Monteiro remains sidelined partner of the Big Lottery Fund, their vital signs during the race. The Hogg Motorsport The project, which is being backwards into the safety barrier, from action and has been ruled with the impact leaving him out of the final round of the Association was awarded a supported by the Global Institute for grant of £30,000 towards the Motor Sport Safety, has been led by temporarily unconscious. season in Qatar on 1 December. Monteiro was extricated from total cost of £76,299. F1 Deputy Medical Delegate Dr Ian With its current emergency the car having regained Monteiro Roberts and F1 Medical Car Driver rescue vehicles now more than consciousness and assessed in is set to Alan van der Merwe. ten years old, the new the circuit’s medical centre. miss four “We know that the monitoring of ambulance represents the first people is essential in terms of their Having complained of concussion, rounds. two blood clots were discovered step in the Association’s rolling medical care,” said Roberts. “Drivers in plan to replace its rescue incidents are no different. We would in his neck, affecting his vertebrae and vision, as well as vehicles with more modern like to start monitoring and assessing ones over the next two to them as soon as we possibly can. But bruising to the left side of his body. three years. the equipment that we currently use is The rescue vehicles are relatively bulky and is only applied In an interview with Eurosport following the crash, Monteiro staffed by the Hogg Motorsport after the incident has happened. Association, a group of 17 There are also times when the driver volunteers who attend more isn’t immediately accessible to us, so if than 130 motor sport event we can’t see him or we’re not actually sessions per year, including the next to him, there’s limited TWELVE HOSPITALISED AT prestigious Isle of Man Tourist information that we can get.” With this new technology, as soon as a championships, with the help of the Trophy. F1 driver Carlos Sainz’s accident driver has an incident we will receive Global Institute. DRAG RACING EVENT As well as serving as a during the 2015 Russian GP is a case physiological readings and biometrics, “The Global Institute has been dedicated rescue outfit for in point. The Spaniard lost control of so he is continually monitored from instrumental in allowing a project like A dozen spectators were taken The Royal Doctors Flying motor sport competitors and his Toro Rosso at Turn 13 during the point zero, through to the initial this to take shape, to give us the to hospital after a competition Service transferred both men, spectators around the Isle of third practice session and hit the response and on to the medical avenues to have access to the teams car sprayed burning fuel into a as well as another two Man, the ambulances are also barrier head-on at 153km/h. centre.” and track time,” adds Van der Merwe. crowd at a drag racing event in spectators, to Royal Adelaide occasionally called upon to Fortunately, he was unhurt but it was Initially the devices will use an Going forward, there are plans to Australia. Hospital for treatment, more The incident, which took than 1,500 kilometres away. support the ambulance service. difficult for the F1 medical team to optical sensor to measure ‘pulse implement sensors for respiratory place at Alice Springs Inland The event was subsequently know this, as part of the barrier came oximetry’, or the amount of oxygen in rate and temperature. In addition to Dragway on 4 September, halted to allow for proper to rest on top of him. When they the blood, alongside the pulse rate. the safety benefits, these will help occurred when the driver of medical intervention to those arrived at the scene, they had to wait “That gives us the most ‘bang for teams and drivers with performance the car began doing burnouts involved. close to a fence, behind which until the barrier was removed before buck’,” says Van der Merwe. “Pulse monitoring. hundreds of fans were knowing the extent of his injuries. oximetry is one of those metrics “They’re the next two big things,” standing. “Accurate monitoring was where for a little information, you can says Roberts. “Respiratory rate gives a Fuel then sprayed out of the impossible until we got hands-on, and deduce quite a lot. You can change very good indication of a driver’s state car and ignited. Twelve people were injured in total, including obviously we couldn’t do that until the what you are doing in a rescue of health and stress, while a 48-year-old man and his barriers were moved,” says Roberts. “If scenario based on that one metric.” temperature is well known for 19-year-old son. Both suffered Hogg Motorsport is we had monitoring on him F1 is just the first step for the device affecting performance. They are the burns on 20 per cent of their bodies, including on their faces. aiming to update all immediately, we could have planned in motor sport as the idea is to filter two for us that we’re going to be FACEBOOK three of its ambulances. our rescue even better than we did. down the technology to other looking at more than any others."

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FEATURES FAST ASLEEP How racing drivers in global series use scientific sleeping plans to stay alert and avoid jet lag

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Jet lag occurs when a race, so we’ve developed a programme which person's internal body speeds it up to about three hours per day. If clock is out of sync with the natural light/dark cycle. you start shifting before you leave, you can be pretty well adapted within a few days of arriving, even with these long trips with a big difference in time zones.”

RHYTHM IS THE ANSWER The circadian rhythm is an internal body clock that is roughly 24 hours in length, and sets us on a daily schedule, letting us know when to sleep, wake, and be active. Modifying this to fit with new times zones, as Dr Lockley explains, is the key when it comes to avoiding jet lag. “The pattern of light and dark helps shift Dr Lockley's methods were the clock more quickly, so we advise when first used to to see light - either sunlight or bright, indoor acclimatise NASA lights - and when to avoid it, by wearing astronauts. sunglasses or not being in natural light. We It doesn’t matter whether you work in an Working with Hintsa Performance, Dr Lockley also offer advice on melatonin treatment, these tips for each driver is of paramount office, on a construction site, or behind the has advised on and formulated individual which does two things. It shifts the clock, importance, as well as following the wheel of a racing car capable of hitting 200 sleeping plans for Mercedes AMG Formula and also helps you sleep at the 'wrong' time guidelines at set times. miles per hour – the benefits of a good night’s One team, ensuring that they get enough when travelling, so it’s very good at helping to “We also ask about people’s sleep habits, sleep are universally acknowledged. shut-eye, and avoid dreaded jet lag when increase the rate of adaptation. duration, their sleep timing, whether they’re Racing drivers today arrive at racetracks all travelling over multiple time zones. “In addition we include naps in the schedule a morning or evening type, and assess some around the world several days in advance, “The travel schedule is quite brutal,” says to help alleviate some sleepiness, as well as of the other factors that might affect the to take part in PR events, team activities, Dr Lockley. “They travel long distances caffeine advice to maximise alertness while schedule, and put them all together in one training, practice and qualifying, as well as potentially every two weeks, and that causes minimising its negative effects on sleep. plan. It’s individualised for drivers so it fits the race itself. problems with jet lag, because the body clock Caffeine doesn’t affect the clock, but it can into their schedule and their biology.” These hectic schedules are carefully can’t reset quickly enough to the changing help you stay awake at times when we want planned and managed by team personnel, time zone. people to see light.” TURBO LAG but to ensure they don’t have a detrimental “I provide plans to the drivers' coaches, These may sound like simple steps to There’s an oft-used phrase that when effect, some racing drivers and teams are who then work with the drivers to help speed follow, but Dr Lockley explains that tailoring travelling on a plane, ‘West is best, East is a now using careful plans to manage their up the rate of adaptation to the new time beast’. Put simply, travelling in a Westerly sleep too. zone. If you don’t do anything proactively, IF YOU DO NOTHING direction is easier for most people, because Dr Steven Lockley, a leading neuroscientist you only shift by up to an hour a day. For it’s following their natural circadian cycle. PROACTIVELY, YOU ONLY SHIFT UP in the Division of Sleep and Circadian example, London to Melbourne is an 11- “ “The direction of the travel also makes a Disorders at Brigham & Women’s Hospital hour time difference, which could take 11 TO AN HOUR A DAY...WHICH WILL difference,” adds Dr Lockley. “Most of us find in Boston, Massachusetts, is one of the days or longer to adapt to without specific TAKE TOO LONG TO BE READY it easier to travel West, because most of us experts working with F1 teams and drivers. advice. This is too long to be ready for the ” have a body clock that is slightly longer than 12 13 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES

This year, Swedish driver Felix Rosenqvist arrive on the Monday and race on Friday, Sometimes not even a strong raced in the FIA Formula E championship, a Saturday and Sunday - you should try to stay energy drink can counter the effects of jet lag series spanning five continents, as well as the busy to get into a normal rhythm. full 2017 Japanese Super Formula season, “I think the best thing to do is to follow the held exclusively in Japan. This meant he day, as in when the sun goes down or when had to criss-cross the globe on numerous the sun goes up, you sort of need to see it, so occasions. it calibrates your brain to the new time zone.” “I’ve been travelling a lot to Japan this Dr Lockley’s research confirms that the year, nine times in total,” he explains. “With light/dark cycle is the most important factor Formula E, there are many races on different with which to reset a person’s circadian continents, and I mainly find that travelling rhythm to a new time zone, although he says East is the hardest thing, so countries like the timing of this must be planned correctly Hong Kong, Macau, Japan are very difficult to to avoid making jet lag worse. adapt to.” “The light/dark cycle is the major Despite racing in two elite motor racing environmental time cue that sets your clock series, Rosenqvist says that the days leading every day, so that you’re synchronised with up to an event are no time to relax, lest you the 24-hour world," says Lockley. "As soon suffer the negative effects of jet lag. as you start to adjust those light-dark cycles “It’s important to stay busy. Let’s say you and sleep-wake cycles, you’re going against

24 hours, but around a quarter of people find you can work out the shortest distance in it easier to travel East, because their body biological time, and shift the clock according clocks are slightly less than 24 hours. to that.” “The extent of the challenge depends on the number of time zones, and also on the MULTI-TASKING internal body clock. When you’re looking As well as the physical and mental demands at solutions for jet lag, you don’t have to of racing for hours at a time, professional necessarily shift the clock in the direction the drivers today often compete in more than calendar says.” one series, taking them to all corners of the Although the preference of Easterly or world in a very short space of time. Westerly travel can have a big effect on the overall plan, it’s sometimes far easier to head the other way around the globe to save time, and reduce the number of time zones I FIND TRAVELLING EAST IS THE travelled through. HARDEST THING, COUNTRIES LIKE “If there’s a difference of 14 hours in one HONG“ KONG, MACAU AND JAPAN direction, there’s a difference of 10 hours Nico Rosberg says he ARE DIFFICULT TO ADAPT TO "slept perfectly and in the other direction, and you caan travel had no jet lag" thanks in either direction. When you’re planning, ” to Dr Lockley's advice.

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your clock, and then you get problems. If you fly to Japan and try to sleep at a time when Rosenqvist experienced QUICK TIPS a 14-hour time zone the brain is promoting wake, you’ll have very I HAD THAT LITTLE BIT EXTRA shift, but managed a poor sleep in Japan, and then when you try BRAIN POWER... I'M SURE THAT'S podium either side of it. Tips to give you the best and stay awake, you’ll have very poor quality “ chances of beating jet lag wakefulness.” PART OF WHY I WON THE WORLD and sleeping better. Rosenqvist’s packed 2017 schedule CHAMPIONSHIP included several back-to-back weekends in JET-LAG different parts of the globe, with one week ” • Start adjusting your incorporating trips to Spain, Japan, and the sleep schedule before USA. However, he feels that a relatively short it revolutionised my life. The advice he gave travel stay in Japan helped prevent any negative was to do it all in small steps, a maximum of • Establish whether you effects. one and a half hours per day, six or seven prefer travelling West or “We did a Formula E test in Spain in the days before you get to the new place. I just East and plan journeys simulator in preparation for the New York slept perfectly and had no jet lag whatsoever. accordingly ePrix, which was on the Wednesday or I had that little bit extra brainpower and • For long journeys, try Thursday before the Fuji race. Then I arrived energy. Anything extra you can bring to the to travel the shorter in Fuji on the evening before free practice, so table is going to help you, and I’m sure that’s distance in biological that weekend was quite crazy! part of why I won the World Championship.” time “I actually felt quite good, because the time I But adjusting to a new time zone early • When you arrive, was there was really short. It’s almost like two doesn’t work for everyone, and is one of synchronise your different theories - you either stay really long circadian rhythm with so that you get adapted or you just deal with Sunglasses at the challenges that Dr Lockley sometimes the light-dark cycle by night might look it for a short period of time. Afterwards I set odd, but it can encounters when putting together a plan. seeing as much of the off straight to New York and I think I arrived help drivers “If a driver has got commitments back natural light as possible there on Tuesday morning, and somehow, adapt to new time in Europe, where it means they can’t start in the day, and avoid zones. I was just immediately into the time zone in shifting their clock early, then we have to light when it’s dark New York, so that was actually one of the work around those issues.” easiest adaptations for jet lag.” Rosenqvist is one such driver, who says GENERAL SLEEP that he has tried to adapt to a new time zone • Cool, calm, comfortable WINNING FORMULA ahead of arrival, but it’s not for him. and quiet room One of Dr Lockley’s main pieces of advice “I’ve tried to get into the time zone before • Use eye masks and is to begin shifting the body clock before travelling, but it rarely works for me, because earplugs to block/reduce travelling. Nico Rosberg, 2016 FIA Formula you have other things to do at home. If you external stimuli One World Champion with Mercedes AMG, start going to bed early before leaving home, • Avoid screens before bed feels that these sleeping plans directly and you sort of jeopardise your whole other life.” as these emit a lot of positively influenced his title challenge. Racing drivers are all different, so there’s alerting blue light “I always struggled through the years with no ‘catch-all’ solution for avoiding jet lag or • Breathing exercises sleeping when I got to different time zones,” dealing with it, but with these personalised can help calm the brain said Rosberg in a recent interview for UBS. sleeping plans, they have very good chances before sleep “The team got advice from [Dr Lockley] and of adapting to new times zones.

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and make things efficient here thanks to all the good people and the willingness there is LAURENT MEKIES in the structure. And when we don’t go about it in a fast enough and efficient enough way, FIA Safety Director the FIA President is the first to push us to Formula One Deputy Race Director perform better. Global Institute General Manager, Research A+M: You are also General Research Laurent Mekies is a man of many titles. Manager of the Global Institute. How does The former Chief Engineer of the Toro this tie in with your FIA role? Rosso F1 team joined the FIA as Safety LM: I think it’s completely integrated really. Director in 2014 and has since added It’s about one safety effort from all the roles as F1 Deputy Race Director and various elements connected to the FIA. Everybody contributes to it and we try to be Global Institute General Manager, as synchronised and as efficient together as Research. But, as he explains to possible so the integration of the safety AUTO+ Medical, they all complement research effort into this big picture is each other to help support one of fundamental. There is a great group of the FIA's main objectives – improving researchers who are very, very skilled and safety in motor sport. experienced, we have super high-level people there and it has been an enjoyable effort to put all that together. AUTO+Medical: It has been three years since you became FIA Safety Director. How have you found the role? Laurent Mekies: The role is fantastic, that’s IT'S HARD TO FIND A the simple truth. After having spent so many BETTER MOTIVATION THAN TO years trying to chase lap times for Formula “CONTRIBUTE TO THE SAFETY One teams, it’s difficult to try and find a OF THE SPORT better motivation than to contribute to the safety of the sport. We have a great team in ” Geneva, we have impressive support from the commissions related to the safety effort A+M: In addition, you are Deputy F1 – from the Medical Commission, from the Race Director. How does that fit in? Circuit Commission and of course from the LM: Of course on paper it’s two different Safety Commission – and at the end of the things – one is a sporting job and one is a day these have allowed us to move things safety job – but in reality having the link relatively fast. People often think things are Mekies joined the FIA between the two is giving us a lot of as Safety Director in going slower in a big institution like the FIA December 2014 advantages on the field. Back in Geneva when but ultimately you can pull things through we try to support the departments and all the

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LM: The Halo is one of our many safety last seven years, and has been central to the research projects, but of course it is one of research work. the most highest profile ones. So yes it took enormous energy from the researchers to A+M: Halo is going to have huge safety first complete the research work, and then benefits, but what are the other once the research work was complete to try considerations for bringing in this device? to make sure we can deploy it in a very tight LM: It’s like for anything, the development is frame that we have from the decision to the in the detail. So we are trying to iron out all start of the racing season next year. On top the items that are now passed to make sure of that, we are deploying it in as many we have as smooth an introduction as categories as possible every time a new car is possible for such an important change. We coming out. In 2018, we’ll have a new are looking into the extrication techniques, Formula 2 car, Formula E will have a new car we are looking at the training for the for season five, in 2019 Formula 3 will have a marshals, we are looking at a large quantity new car… So yes, it has taken a lot of the of perhaps small items that together will research group resources in the last 5-6 make the difference between a smooth months, but I would say that more globally deployment and a difficult deployment. the additional frontal protection project has been one of the key pieces of research of the A+M: Has there been extra training for F1 Working with a Formula One marshals and has this been carried out or team for several years gives Mekies a unique perspective overseen by the FIA? on safety. MY ROLES ARE LM: We are working on that right now, so “COMPLETELY INTEGRATED obviously we did do a number of extrication - IT’S ONE SAFETY EFFORT training exercises before the Halo decision categories of motor sport with the safety LM: I wouldn’t say surprised, because in the FROM VARIOUS ELEMENTS, was taken, and now it’s about finding the best side, it allows us to have a direct, hands- end we are all in the same circus! Really we CONNECTED TO THE FIA way to deploy that knowledge to as many on experience on one of the are all working for the sport and it’s simply people as possible. So we have a Halo plan championships. In F1 we have all the that we’re looking at it from a different angle. ” for medical, which is basically how do we firepower to develop new things and But at the end of the day it’s the same faces bring the medical chain up to speed with the therefore it’s a good accelerator for so it’s quite easy to step from one role to another Halo evolutions, and it’s something that is projects, especially on the research side. because it is a small community, and therefore very much driven by the FIA Medical So this is very valuable for the safety it makes things very easy. I guess the biggest Commission. effort. We also have a similar hands-on surprise is that you are able to move things There will be a dedicated seminar and experience in other championships with forward quite fast at the FIA, nearly as much accreditations that will take place early next our safety delegates. as in the teams. It has been great to see that year in order to support that. Plus a higher with everybody’s contributions and number of training tools such as videos and a A+M: You used to work for an F1 team, willingness, you can push things through. large amount of information, which we have and now you’ve moved over to the made available. We are also producing some governance side. Is there anything that A+M: Speaking of pushing through, we’ve dummy halos to be fitted on all our training Safety training is chassis all over the world so that people can has surprised you from this different got the halo introduced to F1 for next year. "fundamental" for marshals perspective? Is this taking up a large part of your time? train on people and so on.

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A+M: What has been the feedback from CMOs at the circuits? Monaco's marshals show how it is done. LM: I think that everybody now is switching to EVERYBODY NOW IS the fact that ‘OK, halo is out, so let’s make it THINKING ‘HALO IS OUT, LET’S happen as best as possible’, and therefore “MAKE IT HAPPEN AS BEST AS the response we’ve had globally is very POSSIBLE’ SO THE RESPONSE positive. People want to be ready, they want WE’VE HAD GLOBALLY IS VERY to be on time, they want to do things properly. So far the response has been very, POSITIVE very good and we’ve had a lot of inputs and ” advice from all over the world, so this has teams. We do real-life training with an actual been a very positive thing. You have seen also F1 team for example, so training is a that Formula 3 in America has been launched complete central part of extrication. starting in 2018, and even though the deadline is super tight, these guys are going A+M: Finally, what are the other big safety to go with the Halo as well. So I think there is projects that you’re focused on this year? a turning point now that people are getting LM: We have 15 live projects, so to mention on with it and trying to contribute, which only a few... Our new biometric gloves will be is great. aiming to take rescue to the next step by giving our people in the medical car early A+M: Do you think that Formula 1 should information about the vital signs of the have a dedicated safety team which goes drivers so that we can improve the race to each race, similar to NASCAR and recuperations. I think that’s one of the big IndyCar with the Holmatro team? projects for us to deploy that for next year, LM: It’s a very good question. At the FIA we but we have a lot of requests from other have had both models successfully deployed. championships so we want to do it properly In Formula E for example we have a single with one championship next year, with F1, extrication team going to all events and in F1 we do, practice makes perfect. We are very and then if it’s successful we anticipate a very we use a circuit-based team model. I think much training orientated, we like systematic large deployment of that as well and further that both schemes have advantages and training, that’s how we get to the level that we steps to come after that in terms of downsides, but I think we have managed to think is required. You know that on top of all biometrics, so that’s one key one I would say. make both work and there is merit for both the national training that is being done before Then we have a new helmet standard of them, so I don’t envisage a change short an event there is systematic training a few that’s coming for 2019, which will be term for that, for Formula 1 or Formula E. In days before the event when we arrive at the published sometime in 2018. So we will have Formula 1 we have a good system, and in track with our medical delegates and with the a new version of it which is something that Formula E we have a good system. local and national teams to make sure things we change nearly every ten years, so not blend together and are as efficient as every day. We have been working for nearly A+M: How important is regular medical possible. We do static training, we do accident two years now to bring this product to life safety training, not just in Formula 1, but simulation training with the dummy car Accident simulations with the help of one of the key actors in the in motor sport in general for track teams? somewhere on the track and sometimes with are an essential industry and that will be one of the highlights LM: I think it’s fundamental. It’s like anything two cars and sometimes two extrication part of training of 2018.

22 23 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES THE CUTTING EDGE How motor sport rescue teams stay sharp when it comes to techniques for cutting open the super-strong cars of modern times

For just about any racing series in the world, a car that breaks apart easily is an undesirable one. Higher speeds and better technology mean that today’s drivers are always somewhat at risk, but thankfully, with the help of stronger materials and life-preserving survival cells, fragile racing cars are rarely a concern. These resilient cars are excellent at protecting their occupants and absorbing energy. But while safer and stronger cars help minimise injuries, they can present challenges for rescue and extrication teams at racetracks when they need to get inside and manually extricate an injured racer. That’s why as protective environments for racing drivers evolve, so do the tools and techniques used to pry them open in emergency situations. “The cutting abilities of the tools have evolved quite dramatically,” explains Martin Hunt, Rescue Co-Ordinator for the British Automobile Racing Club (BARC). The Halo presents new chal- lenges for extrication teams in “Originally, drivers were removed from cars F1 and other championships.

24 25 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES

Battery-operated tools have with industrial diamonds or tungsten carbide.” largely replaced heavier PART OF THE SKILL Hunt says that Billy Monger’s accident in fuel-powered equipment “IS UNDERSTANDING April, where the 17 year-old driver was THE CONSTRUCTION trapped in the car, was an eye-opener in terms OF WHAT YOU’RE of just how tough single seaters can be to TRYING TO CUT open when a driver is unable to be simply extricated. ” “Until earlier this year when we dealt with has challenges in that it generates a lot of dust the Billy Monger accident at Donington, we and you have to be careful because it can hadn’t really considered the heat problem, break into lots of sharp fragments, risking purely because the carbon fibre we have been injury to both the casualty and the rescuers. cutting has been quite thin – seat shells and “You can use hydraulic equipment, crash helmets are quite thin – but the outside reciprocating saws or angle grinders to cut it, of a single seater is much thicker, and that and UK rescue units carry an oscillating saw, generates a lot of heat when you cut it, so in essentially a plaster saw. Because it oscillates light of that accident we’ve subsequently about 5-10 degrees, it won’t cut skin or found that the best way to cut thick sheets of anything soft, but it will cut hard materials. The carbon fibre is to use these diamond problem with using these tools to cut carbon encrusted blades. Although in this particular fibre is that the blade teeth generate heat as accident we had diamond blades available, the they travel through the material which melts circumstances meant that our option to use by mechanics from their team using standard hydraulic tools. By the 70s, most people were the resin that is used to bond the carbon fibre, them was limited. hand tools – hacksaws, spanners, crowbars using air tools, but they go through air at a so the blades get sticky, and you can’t use “There’s certainly some learning there for and the like, but then things moved on. The terrific rate, so to make sure that you can them anymore. People who manufacture rescue teams. Using a standard tool on carbon UK Motor Sport Association produced a actually complete a job, you needed two air carbon fibre use toothless blades encrusted fibre will work, but it’s quite slow, and you’ll get specification for motor sport rescue with help cylinders. through a lot of blades.” from Derek Ongaro – one of the first Formula “Some fire services and rescue units still use One safety advisors – together with Paul Butt, air tools, but I think the majority of them are ROAD RELEVANCE Paddy Kenshole, John Felix and Dr Bob now using battery tools, because they are Motor sport rescue teams are always learning, Loynes.” lighter, more manoeuvrable and spare and what they learn can be applied to This simple approach with ‘low tech’ cutting batteries are easier to store than air cylinders, everyday motorists. The first carbon fibre devices did the job when cars were built on so we’ve moved on.” monocoque in motor sport was the McLaren ladder chassis and made of sheets of MP4/1, in 1981. Some 11 years later, the same aluminium, but the implementation of A CUT ABOVE THE REST manufacturer launched the first such monocoques, carbon fibre and stronger Carbon fibre is both a blessing and a curse for monocoque on the road; the 1992 McLaren F1. metals over the years meant that more rescue teams. Its lightweight, sturdy design is Road cars have always been behind racing complex tools were required. the perfect component for racing cars, but it Single seaters are cars in this sense, but Hunt says that the “As rescue technology moved along, some of can be tricky to cut. incredibly robust, and knowledge can be passed across. take a long time to cut the equipment that fire services used started “Because it’s made with a weave, there are open when necessary “Some of the challenges we face in motor to appear, such as pneumatic air tools and many ways of cutting it,” Hunt continued. “It sport are only just beginning to impact fire

26 27 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES

far away from your casualty as you can, to the implications of doing that so close to make sure you’ve released any energy. someone’s head are.” “That’s not a situation that fire services Much in the same way that stronger modern encounter. We get some really useful cars present obstacles with cutting pillars and XXXXXXXXX interaction with local fire services in the UK, materials, the fact that the Halo will be fixed to “XXXXXXXX but their skill is in road cars. Competition cars cars and non-detachable means that it may XXXXXXXXX are prepared differently, because they contain need to be dismantled before extraction can XXXXXXXXX roll cages.” take place, as Fiset explains. XXXXXXXXXX “After certain accidents, we don’t know what ANGEL ON YOUR SHOULDER the deformation is going to be. For instance, it ” Formula One and its main feeder series, might be in the way of moving the seat of the Formula Two, are set to introduce the Halo car in a standard driver extraction. We’ve been head protection system for their respective invited to help the FIA with a solution to cut 2018 seasons, increasing frontal protection that if they have to remove it in a hurry. from debris, but maintaining the open-cockpit “If we have a driver still in the seat Carbon fibre has long been in motor sport but is set to become prevalent on nature of single seaters. unconscious and with airway issues, that’s the road as the lighteweight material of And while this titanium structure has been where we’re going to have the biggest concern choice for electric cars like the BMW i3. rigorously tested in regards to deflection tests about the Halo being in the way. Getting to the and driver visibility, the challenge of manually driver’s airway needs to take absolute priority, services. We’ve long been dealing with carbon Holmatro Safety Team, echoes these thoughts, extracting a driver, or indeed cutting away a and is going to be one of the initial challenges.” fibre cars, whereas road cars are only really and says that extrication can be hampered section, has only recently been explored. The height of the device could also prove to just starting to appear in mass production. when cars are bent heavily out of shape. “We did an initial cutting exercise with be a very literal barrier. Though there is no “There’s some reciprocal learning to do there “Road vehicles are now made almost the Holmatro at Brands Hatch,” says Hunt. “The physical wall on the side of the Halo, it - we have experience dealing with carbon way that race cars are, incorporating tubular Halo behaves much how you would expect effectively adds several inches to the outer fibre, and the fire services don’t, and carbon strength, so the metals are very hard. The high-strength steel to behave when you cut it edge of the cockpit, which could complicate fibre has its own challenges if you want to cut it.” difficulty comes when they bend beyond the – it fails very suddenly rather than rescue efforts in some cases, says Fiset. In place of synthetic materials, modern road design of the vehicle. Then you’re dealing with compressing and then cutting.” “Another challenge with the Halo is the cars are largely outfitted with incredibly strong very hard metals that need to be cut, and that The Halo sits just inches away from a driver’s added reach-down into the car, and this could steel alloys, but these are no less difficult to delays the rescue time.” face, meaning that if partial removal of the be a challenge for some rescue packs. I’m not cut in an extrication scenario. Having the correct tool for the job is always device is necessary – perhaps after deformation a terribly tall guy, but I have some tall “Road car manufacturers are under huge beneficial when dealing with an accident, but occurs from being struck by debris – tools colleagues, so their arm reach is going to be pressure to comply with safety standards so Hunt says that understanding the design of must be used with the utmost precision. better than mine.” they can withstand side and frontal impact the car being cut open is even more “You would be cutting close to somebody’s However, Fiset says that the potential life- tests. From this, a load of ultra-high strength important. head and shoulders, so there’s a lot of care saving qualities far outweigh any negatives steels have been developed, and cutting them “Part of the skill of using these tools is required,” Hunt continued. “You don’t have the associated with longer extraction times. is difficult if you don’t have up-to-date understanding the construction of what you’re luxury in that environment of cutting a long “Every time someone complains about a hydraulic cutting equipment. You can cut them trying to cut up, and how it will behave when way away from the patient to release any safety feature, I always look at the bright side. with saws and angle grinders, but it takes a fair you cut it. If you cut the deformed roll cage of stored energy, so there needs to be an If we’re able to extract a healthy driver who is amount of time, it’s noisy and it’s not pleasant a car that’s been crushed heavily, it will move. awareness that there’s a big potential for the less injured and stands a chance of being back if you’re still in the car.” The energy is stored in the bent cage and has sudden release of trapped energy when it in the car in a few weeks, I think that’s just Peter Fiset, regional manager for IndyCar’s to be released, so you need to cut the cage as fails. There needs to be an awareness of what fantastic.”

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In 2018, the FIA Formula One World Championship will host its first French Grand INSIDE THE MEDICAL Prix in a decade, at the Circuit Paul Ricard in le Castellet, near Marseille. Though the circuit plays host to regular track days, national-level CENTRE FOR THE competitions and occasional tyre tests, the challenges of providing medical assistance FRENCH GRAND PRIX and intervention for a World Championship AUTO+ Medical takes a look at the medical equipment, event are another matter. The circuit’s permanent Medical Centre is facilities and operations at Circuit Paul Ricard, as it under the direction of Chief Medical Officer prepares for the first French Grand Prix in ten years. Dr Jean-Francois Amoros, and he expects an increase in staffing of 50-70 per cent over the three-day event, to ensure the medical demands of hosting a World Championship event are met. He works together with a staff of medical professionals and a team of firemen, who are all on permanent alert whenever the circuit is open. The Medical Centre has its own Video Control Room, equipped with four screens, which allow immediate dispatch of the appropriate assistance. The FIA carried out homologation of the circuit's facilities in October, confirming that the facilities were up to standard. Two sets of medical staff will be on alert during the Grand Prix; one for the track, and one dedicated to the public with extra doctors, nurses and first aiders. Dr Amoros talks to AUTO+ Medical about the latest facilities and equipment at the circuit.

Dr Jean-Francois Amoros has been the Chief Medical Officer at Circuit Paul Ricard for the last ten years, and works with a medical team comprised of 18 doctors and 12 nurses..

30 31 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES THE FACILITIES The circuit is well-equipped to deal with medical emergencies. As well as the pictured intensive care unit, Circuit Paul Ricard also has a major trauma facility with two medical beds, a radiography facility, a bathtub for burn victims, an examination room for small injuries, and a recuperation room with two beds.

EMERGENCY VEHICLES The Circuit is equipped with a fleet of emergency vehicles for global events, including two ambulances, two medical cars, two extraction cars and two extrication vehicles. Additionally, an intensive care ambulance (pictured) is at the disposal of the medical team, and is located between the pit lane and the helicopter drop zone.

BURN VICTIMS Situated within the Intensive Care Unit, this "bath tub" is used to treat any patients who have suffered burns in an accident.

VIDEO CONTROL ROOM The Medical Centre team is in constant communication with the track manager, based in the circuit's Video Control Room. They communicate via a dedicated emergency telephone line codenamed 'The red telephone', pictured left. 32 33

All photos courtesy of Morgan Mathurin AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES

THE ROAD BACK:

Bourdais returned to action just eight weeks after SEBASTIEN BOURDAIS sustaining a shattered pelvis, fractured hip and broken ribs The IndyCar racer and four-time Champ Car series champion discusses his remarkable recovery from a 230 miles per hour crash at the 2017 Indy 500

INTERVIEW: JAMES NEWBOLD/ AUTOSPORT

During Qualifying for the 2017 Indy 500, SB: I think there are some plusses and Sébastien Bourdais lost control of the minuses about staying conscious or being rear end of his car at 230 miles per hour knocked out, but I don’t have a strong opinion in the middle of Turn 2. He counter- about that. I kind of wish I had been knocked steered to catch the slide, but the front out because at least then I wouldn’t have been tyres suddenly gripped, and he hit the in so much pain. outer wall at a near 45-degree angle. The resulting impact meant he sustained A+M: What was your thought process after a shattered pelvis, fractured right hip, the accident? and two broken ribs, but amazingly, he SB: There’s always the scary period post-crash overcame these injuries in just eight when everybody is trying to work out how bad weeks to attend a mid-season test, it is. Once I got the bigger picture - that things before making a full racing return in the were broken but nothing that couldn’t be fixed final three rounds of the 2017 IndyCar within a reasonable amount of time - I wasn’t season. He spoke to AUTO+ Medical about too worried. There is the crash at the his injuries and swift recovery. beginning, then the pain, and then you get the analysis and think, it’s not going to be AUTO+ Medical: You haven’t had many pleasant, but we’ll make it through. big crashes in your career, so was this We talked about how things were going to even more of a shock? work out with orthopaedic surgeon Dr Sébastien Bourdais: I’ve never hurt myself Kevin Scheid after he did the surgery, the physically before. I’ve had some sizeable Sunday after the crash. The timeframe was shunts before, but none where I ended up at about six weeks for weight bearing, eight the hospital with an inactivity period, so it weeks for walking and feeling normal, and was all very new to me. then three months to get back in the car. At that point, it was clear to me that the objective A+M: You remained conscious despite the was to get back in the car for the last race, and 118G impact - would it have been better if I was going to be ready for the last race then to be knocked out? I was going to be ready for Watkins Glen, two

34 35 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES

Bourdais instinctively steered into the slide, but the tyres gripped, and sent him into the wall.

weeks earlier. tissue injuries, so you’re never quite sure how which might not be that easy to fix. For us, Providing everything went to plan, there was fast things like that are going to recover. I thankfully, we crash, but we don’t get hurt no reason to sit out the rest of the season. I recovered fairly well and although there are every time. think doctors are always very cautious with better days than others, it all turned out okay.” I certainly wasn’t going to go against the their prognosis, so I guess they told me I was doctors and say, “I don’t care, I’m getting back out for the season to take the pressure off me. A+M: How does it make you feel to have in the car” because with that same mindset I The bone healed pretty well, I don’t have much beaten the projected timeframe for could have done the Indy 500. Physically if point of comparison because I haven’t broken recovery? you’re willing to accept taking the chance, it’s anything before. I had no idea how fast it SB: I tried to follow instructions as best as I possible, but if I had any kind of crash then I would heal but it turned out that my body could, because the last thing I wanted to do was right back where I was, and in worse recovers pretty well. was rush things and make it worse, especially shape. The big concern with the femur neck is at the very beginning when dealing with bone it’s a tricky bone, there’s only one irrigation A+M: What did your physiotherapy consist reconstruction. I tried to be mindful and listen point and if you sever that, then you’re going of, and how did you deal with the injuries? to what they told me because I always had in to need an artificial hip, because the bone is SB: I had broken ribs, so crutches were not mind that a return was possible, and we talked screwed. exactly the best thing for mobility. From the about it. It wasn’t a case of me just saying ‘I’m Bourdais shared In the old days, you would have been in a offset I thought about what the smartest and going to do the last race.’ recovery updates hospital for a month with the injuries that I on his Twitter best way to deal with the injury was going to I started thinking and talking about coming account, walking had - I was out of the hospital after four days. be. My wife hated me using a wheelchair, but back before the end of the season when I had out of hospital Putting everything in perspective, I’ve tried to just four days it was a 15-minute crutches walk, or three been prescribed a timeframe of what was after the crash. be cautious, but once I got the green light and minutes in the wheelchair to get to the rehab going to be allowed, providing certain criteria everything was strong enough to take another place, and I was going three times a day. It were filled. I didn’t do what the Moto GP guys hit, there was no reason to hold back and sit wasn’t very pleasant, but you’ve got to be do, who just ride with broken bones and take out the rest of the season. practical at that time. their chances. They know that if they crash with pins and plates in they could break them, A+M: How satisfying was your comeback A+M: Due to your fitness level, doctors and then they’re going to need more surgery, test at Mid-Ohio? Was there ever a worry operated on both your hip and pelvis that you might not perform at the same simultaneously - did that speed up level as you did before the crash? recovery? I KIND OF WISH I HAD BEEN SB: Inside the car I really don’t feel much of SB: They all said I have a really fast anything as far as the hip is concerned. At the metabolism, which tends to accelerate the “KNOCKED OUT BECAUSE THEN Mid-Ohio test in July, the biggest problem was healing process, but I wouldn’t venture trying I WOULDN’T HAVE BEEN IN SO the neck. I must have pulled a muscle, so I to explain that. Everybody has got their own MUCH PAIN. couldn’t quite drive without padding, but other rate of reconstructing their bones and soft ” @BourdaisOnTrack than that it was all pretty good. It was just a 36 37 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES

matter of doing laps, feeling comfortable, Bourdais started the 2017 sea- and regaining confidence. The test went son in fine form, winning the THE SAFER BARRIER well enough that when I got the all-clear to opening race at St. Petersburg. get back to racing two weeks later, I didn’t Bourdais believes that he days after the crash. think twice about it. would have died if not for Many have likened the It was only three months out of the car, the massive advancements crash to the fatal accident and we have longer off-seasons than that! in motor sport safety over of Gordon Smiley, who was What makes it challenging is the long the last few decades. One killed in a crash at Turn 3 inactivity period, because you lose muscle of the most prominent during Qualifying for the twice as fast when you are mostly sitting introductions, certainly in 1982 Indy 500. Much like or lying down for the first two months. American oval racing, has Bourdais, he steered into a That was definitely a time to work pretty been that of the Steel and slide when the rear of the hard at it to physically get back. Foam Energy Reduction car oversteered, but the (SAFER) barrier. Though front tyres gripped, and he French driver’s injuries too was sent into the wall. were severe, this energy- The car disintegrated, ONCE I GOT THE GREEN absorbing structure helped sending wheels, the engine, “LIGHT, THERE WAS NO REASON reduce the massive 118G the flaming fuel tank, and TO HOLD BACK AND SIT OUT impact at Indianapolis. Smiley himself flying across THE REST OF THE SEASON This, combined with the the track. Though the deliberate deformation of accident was a tragic loss, ” the car’s crash structures Bourdais’ survival 35 and the swift intervention of years later, and incredible A+M: Would it have been harder next the Holmatro Safety Team all recovery, is a testament season if you didn’t return before the contributed to his ability to to just how far safety end of 2017? walk out of hospital just four has progressed. SB: For me, it was very much about giving myself every chance of being successful next year. When we come back in St. Petersburg next year, all I want to talk about is the season ahead, not how I managed to come back and where I’m at physically. For me, it’s important that this chapter is closed, and that we’re focusing on the job ahead instead of unpleasant memories. That was only going to happen if Steel and Foam barriers absorb energy on the people saw me as they used to see me and fast banked corners at not as a guy who has survived something most oval tracks. and is just coming back. I completely understand, but I just wanted to get ahead of it and put it behind me.

38 39 AUTO+MEDICAL SCIENCE AUTO+MEDICAL SCIENCE SCIENCE CONCUSSION IN MOTOR SPORT: A MEDICAL LITERATURE REVIEW AND ENGINEERING PERSPECTIVE

‘WARNING: motor sport can be dangerous’. The spectrum of head injuries in motor sport has shifted dramatically in recent decades, fuelled by advances in medicine and engineering. Despite these successes, there are growing public and professional concerns regarding concussion in motor sport. This review appraises the published literature concerning concussion in motor sport, with particular focus on the current medical and technical challenges in the field. The incidence and assessment of concussion in motor sport is discussed, in addition to modifiable risk factors within and outside the automobile environment. Lastly, areas for further research and development are outlined.

Authors: Naomi D Deakin, Thomas Cronin, Paul Trafford, Stephen Olvey, Ian Roberts, Andrew Mellor, Peter J Hutchinson Impact data suggests that This article has been reprinted with permission from the Journal of nearly 10 per cent of a Concussion, Volume 1: 1–11 | journals.sagepub.com/home/ccn select group of NASCAR collisions between 2002 and 2008 resulted in a mild 41 concussion. AUTO+MEDICAL SCIENCE AUTO+MEDICAL SCIENCE

INTRODUCTION usually self-limiting. However accurate, Motor sport spans a diverse range of events objective diagnosis of concussion remains worldwide, encompassing recreational, problematic in motor sport. Additionally, there amateur and professional competition across are now concerns regarding long-term a broad range of two- and four-wheeled negative neurobehavioural outcomes following vehicles. These automobiles range from the this diagnosis in other sports. historic to the state-of-the-art; designed for Driver safety in motor sport is paramount, the road, circuit, all-terrain and rally; and mitigating concussion is no exception. engineered to withstand desert heat or sub- Recent advances in protective equipment, for zero temperatures of the Arctic. This vast the competitor or their racing environment, array of vehicles is united by competition and have an important role to play in the reduction regulated by numerous governing bodies of concussion. Furthermore, when incidents worldwide, each of whom have differing do occur, it is now possible to analyse the guidelines and recommendations for the causative forces in an effort to prevent similar assessment and management of the rider or injury to future participants. driver diagnosed with head injury. Lastly, in contrast to other high-risk sports Four-time IndyCar cham- The spectrum of head injury in motor sport where the effects of concussion are typically pion Dario Franchitti retired is changing, presenting new challenges to limited to the individual, competitors returning from racing after doctors warned he may suffer staff both trackside and in onward medical to motor sport remain in control of a high- permanent paralysis if he referral centres. The incidence of severe speed vehicle that poses a threat to had another concussion. traumatic brain injury has significantly themselves, other competitors and spectators. decreased over the past decades, thanks to Unsurprisingly therefore, the return to race progress made in the fields of both decision in motor sport is of vital importance engineering and medicine. There appears to and must be carefully conducted by all and ensured that relevant studies were added by the authors, who had access to have been a graduated shift away from professionals involved. obtained. The initial search was complete on historic and offline papers. severe brain injury and towards mild This review seeks to outline the current 18 October 2016 and was updated in January A qualitative review of 127 full publications traumatic brain injury (mTBI) and concussion. medical and technical challenges of 2017. No date limits were applied and studies was conducted by two independent This shift has contributed to reduced concussion in motor sport. Information is were limited to the English language. reviewers; all disputes were resolved. Only mortality in motor sport, yet significant extracted largely from published sources and Search terms related to concussion those studies influential in the field or adding morbidity remains. supplemented by the authors’ own data. The included head injury, mTBI and neurotrauma; new knowledge to the existing literature are The Concussion in Sport Group (CISG), a incidence and assessment of concussion in for motor sport the terms chosen aimed to discussed in this review. panel of experts in sports concussion first motor sport will be discussed, in addition to create as broad a search as possible across established in 2001 and led initially by modifiable risk factors both within and outside amateur and professional racing and RESULTS representatives from ice hockey, football and the automobile environment. Lastly, promising throughout the classes (see Appendix 1). The The problem of concussion in motor sport the Olympic Medical Commission, define areas for further research in the fields of initial search yielded 4575 studies which were With adjustment for national sports concussion as: ‘a complex pathophysiological medicine and engineering are outlined. reviewed using title and abstract. Exclusion participation figures, ‘motor sport’ was process affecting the brain induced by criteria included all non-human studies. attributed the highest rate of concussion (181 biomechanical forces’. Concussion is largely a METHOD Secondary searches of bibliographies added per 100,000 participants; 0.18%) in a nine- clinical diagnosis, classified by some as a A MEDLINE search strategy was developed and further publications which were assessed year retrospective study from Victoria, subset of mTBI, which encompasses a adapted for use in PubMed, TRIP and with the criteria outlined above. A small Australia.1 This retrospective analysis heterogenous spectrum of disease and is Cochrane. Scoping searches refined the terms number of additional publications were identified 4745 hospital attendances for

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sports-related concussion, with motor sport with minor head injury over a five-year literature explores concussion in motocross Racing League (IRL), where a survey of 124 as the cause in 14% (n = 674); third behind period, representing a far lower prevalence of events. A retrospective study conducted at a drivers during four racing seasons (1981– Australian football and cycling. The nature of 6.3%.2 Additional estimates of prevalence single US trauma centre analysed injuries 1984) found that only 13 drivers reported participation was not defined. However, across recreational and competitive motor attributable to a nearby annual motocross previous head injury (defined as loss of analysis of all types of motor racing at a sport are outlined in Table 1, in addition to competition; 51 competitors from four consciousness (LOC), with admission for single circuit in the United Kingdom found calculation of an annual rate. annual competitions attended the facility, observation or treatment), a prevalence of that 23 of 364 competitors were diagnosed A relatively large portion of the motor sport with 16% (n = 8) diagnosed with concussion 10.5%. Throughout the study period, IRL and during the study period.4 A similar analysis of Championship Auto Racing Teams (CART) had Table 1. Overview of concussion diagnoses in motor sport from the published literature: proportion of diagnoses emergency department attendances at a comparable rates of head injury at 16.6% and and annual rate of concussion. single centre in the United States found that 17.6%, respectively. Of note, all competitors 9.5% (n = 56) of all treated injuries were returned to competitive driving.14 In contrast, concussion in motocross and all-terrain figures from 12 years later (1996–2000) give vehicle riders.5 In a separate study, when an incidence of 1.2 concussions per 1000 surveying an entire motocross racing season, drives. This data is from a single-centre four- it was found that 48% (n = 67) of riders year retrospective study at the Fuji Speedway experienced at least one self-reported which investigated all injuries presented to symptom of concussion.12 These results were the circuit medical centre, encompassing translated to Emergency Department professional saloon car and single seat attendances in a separate study at the same racing. Concussion was defined as any driver institution, where it was found that between with amnesia or confusion and diagnosed in 2000 and 2007, 19% (n = 57) of all 3 out of 112 drivers (2.7%).6 The most recent attendances were attributed to concussion. study, a retrospective analysis of all National Finally, providing a national overview for the Association for Stock Car Auto Racing United States, an 11-year retrospective study (NASCAR) impact data from the 2002–2008 using the National Electronic Injury race seasons, found that head injury (mild Surveillance System database recorded concussion, with or without LOC) occurred in concussion as the most common form of 27 of the 274 selected impacts (9.9%). These head and neck injury in motocross (although data are difficult to interpret, but are the only participant level was not defined), accounting published information for this racing series.7 for 29% (n = 22,788) of these injuries.13 In In contrast, unpublished data from the British summary, concussion in motocross is Touring Car Championship (BTCC) and its highlighted as one of the most common support series illustrate that the incidence of injuries sustained, with presentations ranging concussion may be increasing. Formal from 9.5% to 19% in competitive events. diagnoses from the Race Medical Director numbered zero to one annually in the early Rates of concussion in professional 1990s and are now in double figures. Data motor sport from the most recent seasons are as follows: Disappointingly, much less data have been 6 (2012), 7 (2013), 8 (2014), 11 (2015) and 6 published for professional motor sport (2016). At the time of writing, one diagnosis of racing. The earliest published study of concussion has already been made during professional four-wheel racing is from Indy pre-season testing in the British Formula 4

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Championship (certified by the Fédération Internationale de l’Automobile (FIA) and GOVERNING BODIES concussion throughout their careers.8 A Computerised neurocognitive tests powered by Ford). “HAVE DIFFERING GUIDELINES quarter of drivers (n = 10) admitted to There has been a wave of computerised A small body of literature relates specifically AND RECOMMENDATIONS concussion during their racing lifetime. neurocognitive tests (CNTs) in the past to professional two-wheel competition, FOR THE ASSESSMENT AND Concussion and head injury were the decade, which aim to objectify the diagnosis extracted from exhaustive MotoGP data. A MANAGEMENT OF HEAD second most common injury-related fear of concussion. More recently, these platforms study of three US MotoGP races in 2013 amongst the surveyed participants. have become internet-based, and all have (including practice sessions, qualifying and INJURIES standardised and often automated scoring race) recorded 78 crashes, with an incidence ” Diagnosis trackside systems. These ready-prepared tools are rate of 9.7 crashes per 100 rider hours. Ten have also included LOC; however, this is no Only one motor sport governing body employed across a huge range of sports riders attended the medical facility, with two longer a diagnostic criterion. Indeed, recently publicly mandates the diagnostic tool internationally and implemented by a variety diagnosed with concussion, resulting in a published literature highlights that LOC utilised for concussion trackside. The of medical personnel. disproportionately high proportion of occurs in less than 10% of sports-related Federation Internationale de Motocyclisme The Immediate Post Concussion concussion diagnoses (20%).9 A far smaller concussion. The lack of clear clinical (FIM) states that: "in the event of a Assessment and Cognitive Testing tool proportion of concussion diagnoses was diagnostic criteria and objective diagnostic suspected concussion, the rider should be (ImPACT) was created in the 1990s and collected from the internal database of the tools results in real challenges for those assessed using a recognised assessment employed by many professional American ‘Clinica Mobile’ medical team during the 2014 providing medical cover for motor sport tool such as SCAT3 (Sports Concussion sports associations, including the National season, encompassing MotoGP, Moto2 and events. Assessment Tool) or similar".15 Of note, Football League, National Hockey League and Moto3. Injury was defined as the ‘inability to SCAT3 includes a neck examination and Major League Baseball since its inception. race or train’, and of the 191 recorded, 1.6% Diagnosing concussion in motor sport additional symptoms which are not This CNT is performed in 45 minutes and (n = 3) were concussion.10 The poor specificity of concussive symptoms included in the previous version, SCAT2. produces four composite scores: verbal was highlighted in the published literature by Internal guidelines for Indy Car advise the memory, visual memory, visual-motor Concussion in the adolescent Luo et al.,11 who found that a large proportion use of SCAT3 at on-site medical facilities. processing speed and reaction time. Regardless of amateur or professional racing of competitors continued to display Colloquial sources also suggest that the A formal review of ImPACT in sport status, there is a growing number of symptoms of concussion throughout the King-Devick is utilised, but this is not highlights that the validity and utility of this adolescent participants in motor sport. racing season.12 Similarly, Colburn and Meyer corroborated in published literature or CNT is strongly affected by environmental, Analysis by this sub-type is largely under- concluded that concussion figures were likely available guidelines. administrator and participant factors.16 represented in the literature; however, a to be under-documented, despite Extrinsic factors include the suitability of the single study provides data for adolescent representing the most common non- testing environment and the clarity and Fernando Alonso motocross riders during the 2000–2007 orthopaedic injury identified in their cross- missed the first reproducibility of administrator instructions. seasons. A total of 299 injuries were recorded sectional study.11 The same study also race of the 2015 Participant factors included physical exertion F1 season after in 249 patients, of which head trauma with examined self-reporting of concussion in being concussed and hours of sleep prior to testing. The same LOC was reported in 18% of cases. There was motor sport, one of only two publications to in a testing crash. review highlights that 10%–35% of athletes an average of 1.37 concussive episodes do so. A questionnaire was utilised to report could intentionally under-perform in their during the study period (range one to five), on the types of injuries sustained during four baseline assessment, thus invalidating their and 33% of riders reported repetitive head international six-day Enduro events. Of the post-injury measures. In a separate injuries during the seven-year study period.3 172 drivers, 121 were injured during the publication, the authors stated that these study period and only 7% (n = 9) reported threats to validity could be addressed by Assessment and identification concussion. Self-reporting was further rigorous standards of clinical practice.17 Key clinical features of concussion include analysed by a mixed methods questionnaire Further exploration of measurement error confusion and memory loss of varying study of 40 American professional stock car for ImPACT in the systematic review found degrees and duration. Historically, definitions racers who reported on the diagnosis of that 22%–46% of participants experienced a

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acknowledged that changes in driver racing series, published in 2002.21 The Head and Neck Support velocity greatly influence clinical outcome. In direct response to a dramatic rise in (HANS) device was introduced in In contrast, a more in-depth review by severe head injuries in the IRL during the CART in 2002, before being made mandatory by the FIA in 2003. Lloyd and Conidi collates data from 1997 season (n = 7), the race medical team biomechanists and sports neurologists, personnel collaborated with engineering concluding that helmets do not produce colleagues to alter the composition and significant protection against concussion, location of the in-car padding. This change although severe brain injury (such as not only reduced severe head injuries but subdural haematoma) was the main also minimised the incidence of concussion. exploratory aim.19 Finally, a single study This positive affect persisted throughout the was identified which specifically 1998 and 1999 seasons.22 Other attempts at commented upon helmet use and modifying in-car protective measures in order concussive symptoms in motor sport. to minimise concussion have included safety Prospective analysis of motocross riders at harnesses23 and airbags; the former a regional racetrack during the 2010 successful and the latter not.24 season found that professional helmet fitting was associated with a 41% decrease Altering the competitive environment in the development of concussive There is a large amount of literature which symptoms. The use of neck braces was investigates the magnitude of a single impact found not to correlate significantly with a sufficient to cause brain injury; however, few reduction.3 studies specifically comment upon The Head and Neck Support device concussion. Furthermore, the varied nature (HANS) was first introduced by CART in of motor sport incidents (their speed, 2002 and mandated by the FIA in 2003. The direction and magnitude) provides a unique HANS was designed with the aim to reduce platform for analysis of the causative forces change that exceeded the measurement other selected international series. Use of fatal cranio-vertebral dissociation injuries implicated in concussion. error in at least one ImPACT composite score; ImPACT is also advised by the FIM, AMA by transferring the weight of the helmet The relationship between vehicle representing an unreliable change.16 This ProRacing and the CNT of choice for Indy Car. and head impact loads to the shoulder gravitational (g) forces sustained at impact review questioned the diagnostic accuracy of belts. HANS prototypes were tested using and subsequent brain injury was examined ImPACT, owing to the poor to moderate PROTECTIVE MEASURES TO MINIMISE track, sled and direct impact tests in an during IRL car crashes from 1996 to 2003. For reliability of most scores. Indeed, it was CONCUSSION IN MOTOR SPORT initial biomechanical feasibility study, the purpose of analysis, the impacts were specifically stated that: "it is hard to establish Competitor protective equipment: which also implied a theoretical reduction separated into those sustaining either <50 g the diagnosis of concussion on the basis of helmets, HANS and headrests in head injury.20 This ideology is supported or >50 g. Almost a fifth of those drivers ImPACT testing alone".16 The theoretical utility of helmets in by data from a single study of the CART sustaining an impact >50 g were diagnosed To date, there have been no publications preventing concussion is stated as two-fold in with a head injury (16.0%, n = 30), compared which specifically analyse the use of ImPACT a review by Barth et al.18; firstly, "the HANS WAS DESIGNED TO to 1.6% (n = 3) in those of <50 g (P < 0.001). in motor sport, yet ImPACT has been utilised cushioning effect of helmets increases the REDUCE FATAL INJURIES BY The mean peak g for those with head injury without specific validation in this field since distance of deceleration and reduces the “ was 79.6 g (SD = 28.5) versus 50.6 g (SD = 28.0) the early 2000s, in the absence of an forces associated" and, secondly, on a more TRANSFERRING THE WEIGHT in those with no head injury (P < 0.001).25 alternative CNT. ImPACT was first mandated basic physical level, the use of helmets OF THE HELMET AND HEAD Additional impact metrics associated with by CART in 2002, later by NASCAR in 2014 and increases the surface area across which the IMPACT TO THE SHOULDERS head injury were explored during the 2002– currently mandated by FIA for Formula 1 and blow or force is absorbed. Regardless, it is ” 2008 NASCAR seasons. National Aeronautics 48 49 AUTO+MEDICAL SCIENCE AUTO+MEDICAL SCIENCE

and Space Administration (NASA) injury- Road driving after concussion Table 2. The first MSA concussion guidelines, published in Formal motor sport guidance modelling techniques were utilised to re- For those road drivers with severe the annual update of the Yearbook, on 1 March 2016.36 The ongoing desire for formal guidance create the recorded crashes (n = 274), of concussion, it has been shown that both task regarding concussion in motor sport has which 27 resulted in head injury (defined as and driving performance are reduced after recently been characterised by an online 30 mild concussions, with or without LOC). Four injury. Furthermore, objective studies have A11. Concussive injury can be serious, especially if survey published in AUTO+ Medical, where metrics correlated well with subsequent head also shown that traffic hazard perception is repeated within a short period or in the younger age 65% of the medical participants found it injury: head resultant acceleration, head impaired in the short-term following group. For this reason, the MSA has introduced this difficult to assess a competitor for concussion policy restricting activity following this type of injury. change in velocity and head injury criterion concussion;31 however, this is not replicated Concussion is diagnosed following an accident and over 99% requested further guidance (HIC) 15 and 36.7 Furthermore, in in the long-term after self-reported including the following symptoms: regarding returning to race decisions.29 • Transient unconsciousness (not always present) 32 reconstructive analysis of a single motocross diagnoses. A small quasi-experimental case– • Confusion/disorientation The FIM publish a comprehensive Medical accident, peak change in rotational velocity control study examining road driving has also • Amnesia Code, which advises that: "Assessment of the • Headache and HIC correlated with maximal principal shown that patients with mTBI should not • Dizziness/nausea injured rider and return to competition strain on the brain. The authors concluded drive for 24 hours; however, the optimum Following diagnosis of one or more of these should be in accordance with the guidelines that rotational kinematics contributed period for abstinence was not explored.33 symptoms, this policy must be instituted by the for the assessment and management of meeting/event Chief Medical Officer or equivalent. insignificantly to the pressure response A11.1. The competitor must not compete further in the concussion as contained within the (which in turn correlates with brain injury).26 Recommendations for other sports meeting/event (including subsequent days). International Consensus Statement on A11.2. The competitor’s licence should be suspended and 15 Finally, the type of impact most likely to result The most influential guidelines for the retained by the Clerk of the Course, then forwarded Concussion in Sport Zurich 2012". In a direct in LOC was highlighted by analysis of NASCAR management of concussion in sport are to the Medical Department of the MSA, together statement of concordance to the above, the crashes over a three-year period, identifying produced by the CISG, who first met in Vienna with a note explaining the reason for return. guidelines also state that: "the rider should A11.3. Upon receiving the licence, the MSA will send the lateral motion as the causative factor. in 2001, where a consensus definition for licence holder an explanatory letter with a pro immediately be excluded from competition Unfortunately, however, concussion was not sports-related concussion was produced. forma for them to take to their GP or licence for at least the rest of the event" if a medical issuing doctor. This will ask the doctor to 27 specifically mentioned. This final notion is Minor revisions were made in Prague in 2004 confirm the absence of symptoms. concussion is diagnosed. Return to race is supported by analysis of the neuromuscular and Zurich in 2008. During the most recently A11.4. Upon receipt of the pro forma, certifying the then dictated by documented formal absence of symptoms, the licence will be returned. capabilities of professional racing drivers, published meeting of the CISG (Zurich, 2012), Any concerns should be notified to the Chairman of assessment of resumption of: "normal neuro- where it was found that open-wheel concussion was formally defined as: "a the Medical Advisory Panel. psychological function", where the use of competition resulted in stronger lateral neck complex pathophysiological process affecting A11.5. It is important that the competitor is advised not to ImPACT or functional MRI is advised. AMA drive any vehicle until symptoms have resolved. 28 flexion musculature. the brain, induced by traumatic biomechanical They should also be advised to consider discussing ProRacing similarly advises ‘passing’ of an forces".34 Five major features were defined their employment role with either their ImPACT assessment prior to returning to Occupational Health Department or General 35 RETURNING TO RACE: CURRENT relating to the causative event, resultant Practitioner. competition, a stance which is replicated by GUIDELINES IN MOTOR SPORT symptomatology and absence of radiological A11.6. Professional racing series, where regular medical Indy Car. A recent survey published in the FIA medical changes. Additionally, same-day return to play personnel attend, may institute their own policy, The UK Motor Sports Association (MSA) provided this policy is followed as a minimum. journal, AUTO+ Medical, found that 70% of was eliminated for any athlete for which there A11.7. The duration of symptoms is variable, with most introduced its first concussion guidelines into competitors: "did not feel completely normal" is a suspicion of concussion. Outside of these cases recovering within a period of two to three the MSA Yearbook in early 2016 (Table 2), weeks. This policy should generally cover that 29 when they attempted to return to race. guidelines, the general clinical consensus is period. Some cases have persistent symptoms, in advising removal from competition for 14–21 There are no formally published studies that athletes should be asymptomatic and these cases, expert opinion should be obtained. days after a diagnosis of concussion.36 A11.8. A second episode of concussion, occurring within a examining return to race decisions in motor cognitively unimpaired before a return to play period of three months will require specialist Similarly, Speedway New Zealand mandates a sport after concussion, and therefore, this (or race). For contact sports, the recovery time referral prior to the return of the licence. 22-day stand down period for any driver process must be guided largely by data from sports-related concussion is estimated as diagnosed with concussion, which can be Source: MSA Yearbook 2016, reproduced with permission published for road driving and other sports. 5–10 days after injury. from the MSA, 28 February 2017. reduced to an absolute minimum of 15 days, MSA: Motor Sports Association. pending formal medical assessment and Board approval.37 There are no formal

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published guidelines from NASCAR or the FIA. and relates the mitigation of translated forces Regarding the latter, concussion seems only during impacts. CHAMPIONSHIP-WINNING importance and can be lifesaving. A serious to be loosely covered by Article 1.5.3 of As elucidated in a systematic review of the incident will not only impart considerable Appendix L to the International Sporting ImPACT assessment, new directions for “VEHICLES WITH POTENTIALLY accelerations to the vehicle chassis and Code: "any health problem that might, objective assessment in concussion include HIGHER ACCELERATION MUST directly to the competitor but also cause because of its nature or the treatment balance testing (such as the sensory BE MITIGATED BY DRIVER significant relative velocities between the required, result in consequences that are organisation test), ocular-motor assessment PROTECTION SYSTEMS head and the in-car environment. A head harmful to participation in motor sport (visual ocular motor screening) and cognitive- protection system must therefore be including in case of an accident".38 balance dual tasks paradigms.16 These tools ” designed to manage these forces. The must be utilised carefully however with competitors would like to learn more about primary aim of this equipment is to absorb AREAS FOR RESEARCH AND DEVELOPMENT stringent normative values, since research concussion.29 Worryingly, half of the reported significant amounts of energy, whilst ensuring The medical management of concussion has proven that motor sport athletes attain concussive episodes in this study had not that the loads, pressures and accelerations Frontiers in the medical management of superior visual performance when compared been discussed with a doctor, further imparted to the head do not exceed injury concussion in motor sport are broadly two- to controls.39 Furthermore, accurate diagnosis indicating that concussion may be more thresholds. From an engineering perspective, fold. The first is clinical and relates to the of concussion requires competitor prevalent than is currently understood. the greatest challenge in motor sport lies in trackside diagnosis of concussion and the engagement and education; a recent survey The notion of incident analysis informing mitigating the relatively high change in return to race decision; the second involves described previously from AUTO+ Medical technological advances in motor sport was velocity together with the very short stopping collaboration with engineering colleaguesa highlighted that 76% of participating proposed by Olvey et al.40 as early as 2004 distance available on track. Currently, and has recently been translated to the use helmets used in motor sport are typically of simulated driving studies.41 The latter is homologated to absorb energy at supported by evidence from 2006, which acceleration levels of up to 300 g. This concludes that simulated driving is threshold exceeds that of the headrests in comparable to road use but lacking the single-seater vehicles, which are designed for emotional component.42 275 g for severe and 100 g for minor accidents. These latter values are considered Engineering a reduction in concussion a compromise to ensure head protection Driver safety has become a cornerstone of over a full spectrum of accident severities, motor sport regulation, embraced by whilst ensuring optimum protection via the engineers and medical professionals alike. helmet. The threshold g values for severe However, the requirement for championship- head injury were clarified by analysis and winning vehicles with potentially higher reconstruction of 10 motor sport accidents longitudinal and lateral accelerations has to with significant head injuries, concluding that be carefully mitigated by driver protection 100 g corresponded with head accident injury systems, which in themselves can add extra severity (AIS) score 1 and 300 g with head AIS mass, cost and other unforeseen effects. The score 3.44 To date, no studies have relationship between medical and investigated the g forces specific to the engineering professionals was concisely development of concussion, although the summarised by Lippi et al.43 Andy Mellor, threshold is suspected to be considerably Formal diagnoses of concussion have increased in BTCC, with 38 Senior Research Engineer at the Global below 100 g. incidences observed from 2012-16, Institute for Motor Sport Safety, provides An important future contribution to the compared to incidences of 0-1 per insight into these technical challenges. technical aspect of motor sport will come year in the early 1990s. Head protection in motor sport is of vital from the analysis of racing incidents. The

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preferred data capture method in the motor sport field was undoubtedly the professional motor sport currently is the late Neurosurgeon Professor Sid Watkins, deployment of in-ear accelerometer systems former President of the FIA Institute for which are used in Formula 1 and Indy Car. Motor Sport Safety. In addition to The Formula 1 system measures 0 to ±400 g revolutionising driver safety in motor sport, in three orthogonal axes, at a sampling rate Professor Watkins assessed all injured of 1000 Hz. A single unit is moulded within competitors in FIA Formula 1 and the BTCC the silicon earplug for each ear, incorporated during his extended career. This singular within the communications system. In approach to concussion is now not possible addition to measuring linear motion, there is in motor sport as a result of ever-increasing theoretical potential for the measurement of race team pressures and fierce commercial rotational acceleration. By employing a six- interests, on a background of more prolific axis linear accelerometer system, it may be litigation and high-profile medico-legal possible to measure rotational accelerations rulings in other sports. In fact, there now about the X and Z axes. This approach relies exists a significant knowledge gap for on measuring the difference between linear concussion in motor sport specifically. accelerations from the left and right ear Extensive review of the published pieces. Mathematically, a pure rotational literature has established that motor sport The late Professor Sid Watkins oversaw mas- acceleration of 10,000 rad/s/s about the Z has a relatively high rate of concussion sive advancements in axis (yaw) would cause a linear acceleration when compared to other sports, but the motor sport safety dur- ing his career, including of +50 g in one ear and −50 g in the opposite data are variable depending on the vehicle, Formula One's adoption ear. If future accelerometer systems had an class/championship, country, level of of the HANS deivce. overall accuracy of ±5 g then a resolution of competition and terrain. Furthermore, it is 1000 rad/s/s could be achieved, which could difficult to interpret these data since a greatly assist in the elucidation of the significant proportion of the published prevalence of concussion in motor sport. particular, rates of concussion in the BTCC causative forces for concussion. Secondly, to literature is descriptive or observational. In This latter idea is supported by the recent and its support series appear to be measure rotational accelerations about the Y addition, the most informative studies are finding that the majority of competitors have increasing; a fact which requires further axis it may be possible to fit micro rate- retrospective and frequently rely upon historically failed to seek medical advice investigation. Lastly, there is a growing sensors, a prospect currently under emergency department attendance figures following a concussive episode. representation of adolescents in professional investigation. Finally, high-speed filming could or nationally collected data, which are not In contrast, the published data for motor sport, however this group remains be employed to determine rotational specific to motor sport. Therefore, it is professional motor sport appear to indicate under-represented in the published position, differentiating for both velocity and possible that the data presented may lower rates of concussion. However, there literature. Studies investigating non- acceleration. The theoretical basis for this misrepresent the actual incidence or are few studies which investigate this sector professional competitive motor sport indicate measurement has been proven of motor sport specifically, and the diagnostic that repetitive head injuries are problematic; mathematically, such that with adequate criteria are disparate, largely attributable to a significant cause for concern in the frame rates and resolution, it would be THERE ARE A GROWING variation in publication date. Superficial developing brain of a professional motor possible to measure velocity accurately and “NUMBER OF ADOLESCENTS analysis of the small amount of published sport athlete. However, regardless of acceleration to a certain extent. IN MOTOR SPORT...THIS data indicates that American series, such as professional or amateur racing status, there GROUP REMAINS UNDER- Indy and NASCAR, have lower rates of is a growing number of adolescent CONCLUSION REPRESENTED LITERATURE concussion than in competitive activities participants in motor sport globally, and The most influential medical professional in ” utilising similar vehicles in other countries. In medical professionals must recognise the 54 55 AUTO+MEDICAL SCIENCE AUTO+MEDICAL SCIENCE

significant contribution of this cohort to by investigating and analysing motor sport ACKNOWLEDGEMENTS concussion, especially when cognisant of the incidents. The deployment of in-ear The authors would like to thank the FIM, second impact syndrome. DESPITE THE POPULARITY accelerometers to a broader range of MSA and BTCC for their comments upon Review of the medical literature exploring OF MOTOR SPORT, THERE IS A championships would provide a much- this review. the protective measures employed to reduce “MISMATCH OF RESOURCES TO needed increase in the amount of data head injury/concussion highlights that MEDICINE available worldwide. The use of additional DECLARATION OF CONFLICTING INTERESTS partnerships with engineering colleagues technology, such as micro rate-sensors and The author(s) declared the following potential have been employed successfully in recent ” high-speed video, may prove valuable tools to conflicts of interest with respect to the years to reduce rates of concussion. This support this analysis. These tools are limited research, authorship, and/or publication of collaborative approach may be an efficient management of concussion in motor sport currently only by team, championship or this article: ND receives expenses in exchange way in which the competitive nature of the could be mitigated by prospective, large regulatory body engagement. Caution must for performing baseline and post-concussion sport can be maintained in the safest scale, international studies of high scientific continue to be employed in the interpretation neurocognitive testing for the BTCC and its manner. Furthermore, it will be vital to standards designed to accurately define the of these data, however, since helmet motion support series. PT is a member of the FIA extend such collaboration to incident analysis exact incidence and prevalence of concussion may not translate to that of the head, the Medical Commission, MSA Medical Advisory where a knowledge gap exists for the in motor sport, which remain unclear. The brain or its microarchitecture. Even with such Panel, and Research Working Group of the threshold values for concussion. The field of need for motor sport-specific studies also caveats, the data from these tools may be Global Institute for Motor Sport Safety. He is motor sport, with its close links to frontiers in extends to the assessment and diagnosis of combined to develop improved performance also a Medical Director for the British Touring technology, is a fertile ground for multi- concussion; ImPACT remains the only CNT targets for future head protection systems, Car Championship and Medical Advisor for: disciplinary collaboration, and this provides commonly utilised in the field, yet has never applicable not only to motor sport but also to Porsche Motor Sport, Renault Motor Sport, an excellent opportunity to elucidate the been formally validated for motor sport. road users. Ginetta Motor Sport, Ford Motor Sport and the non/-impact-related causative factors of Finally, return to race decisions could be Despite the popularity of motor sport in the FIA/MSA Formula 4, and Chief Medical Officer concussion and the relative contribution of augmented by simulated driving scenarios lay domain and the vast amount of financial for the British Automobile Racing Club. SO is a linear versus rotational forces. supplemented by eye-tracking technology investment in the engineering aspect of the Member of the FIA Medical Commission, Perhaps the most influential decision made and measurement of reaction times. Such sport, there remains a mismatch of resources Consultant to Indy Car and Director of the by a medical professional is that of a studies would allow competitors to be more to medicine and a resultant paucity of International Council of Motorsport Sciences, competitor returning to race after a aggressive in their driving style, without medical research in the field. Concussion is ICMS. IR is the FIA Formula 1 Deputy concussive episode. Currently, competitors compromising their safety, or that of other an evolving problem which appears to be Permanent Medical Delegate. AM is a Senior appear to be relatively poorly informed competitors, and indeed a similar approach more prolific in some series as compared to Research Engineer for the Global Institute for regarding the diagnostic criteria for could be utilised for specialised onward others, yet the causative forces remain Motor Sport Safety. PH is supported by a NIHR concussion, with the ideology that LOC is a rehabilitation. The applicability of new largely undefined. There exists a real Research Professorship and the BRC necessary component being perpetuated objective diagnostic tools for concussion to progress in the global assessment and Cambridge NIHRm, and is also Chief Medical even in professional series. Additionally, highly specialised motor sport athletes could diagnosis of concussion and the prospect of Officer for the FIA F1 British Grand Prix. there is no established ‘safe period’ in the also prove invaluable. new objective diagnostic tools could literature for return to driving in general, not From an engineering perspective, the revolutionise the field. However, the challenge FUNDING least for competitive activity. The 2016 Berlin current technical challenges of concussion in for motor sport will lie in incorporating these The author(s) received no financial support update of the CISG guidelines are eagerly motor sport centre around the need to advances into guidelines applicable to the vast for the research, authorship, and/or awaited by the medical community. Their balance driver safety against race team array of national and international motor publication of this article. adaptation and incorporation into readily success. Despite this difficult task, there sport governing bodies, across a range of accessible formal motor sport-specific remains a significant potential to greatly amateur and professional competition. SUPPLEMENTARY MATERIALS concussion guidance is a necessity. improve knowledge of the physical For further information regarding this The current challenges in the medical mechanisms and thresholds for concussion publication, please contact the lead author.

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CALL FOR SUBMISSIONS Every issue of AUTO+ Medical contains a scientific research paper that looks at the various medical issues that surround motor sport.

All submissions are welcome For each submission please AUTO+ MEDICAL so if you have a study that include a summary of the EDITORIAL BOARD you feel would be suitable research and all necessary for publication in future contact information. Dr Paul Trafford issues of AUTO+ Medical, (Chairman) please send it to: The editorial board will [email protected] evaluate each submission Dr Robert Seal before it is accepted for use (Medical Director, in the magazine. Canadian Motorsports Response Team)

Dr Matthew Mac Partlin (Assistant Chief Medical Officer, Australian GP)

Dr Pedro Esteban (FIA Medical Delegate, World Rallycross Championship)

Dr Jean Duby (FIA Medical Delegate, World Rally Championship)

Dr Kelvin Chew (Chief Medical Officer, Singapore GP)

Dr Jean-Charles Piette (FIA Special Medical Delegate)

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